Provider Demographics
NPI:1821732660
Name:BAZAN, MERCEDES
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:BAZAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 CASTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2028
Mailing Address - Country:US
Mailing Address - Phone:718-354-5502
Mailing Address - Fax:
Practice Address - Street 1:669 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2028
Practice Address - Country:US
Practice Address - Phone:718-354-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency